Definition

 Chronic bronchitis is a clinical diagnosis of sputum expectoration on most days

during at least 3 consecutive months for more than 2 consecutive years

Signs and Symptoms

 Symptoms of exacerbation are increase in dyspnea, sputum volume & sputum

purulence over baseline

Risk Factors

Risk Factors for Exacerbations

 Tracheobronchial infections (eg influenza, streptococcal infection)

 Environmental exposures (eg air pollution)
 Noncompliance with oxygen therapy or pulmonary rehabilitation program

Diagnosis

Diagnosis is typically based on clinical presentation.

History

 History of chronic bronchitis with acute onset of symptoms which include the
following:
o Major criteria: increase in sputum volume, increase in sputum purulence &
increased dyspnea
o Minor criteria: wheezing, sore throat, cough & symptoms of a common cold
(eg nasal congestion/discharge, fever, 20% increase in respiratory rate or heart
rate above baseline)

 Exacerbation is usually considered if at least 2 major criteria are present or depending

on the definition used, the presence of at least 1 major & 1 minor symptom for at least
2 consecutive days

Physical Examination

 There are no characteristic physical findings in acute exacerbation of chronic

bronchitis (AECB) but the following physical findings may be found:
o Increased respiratory rate
o Increased wheezing
o Diffuse crackles without localization, may be present
  Consider the possibility of pneumonia if there is evidence of consolidation (eg
localized crackles, bronchial breath sounds, dullness on percussion)
 Elevated body temperature usually suggests viral infection or underlying pneumonia
as a cause of an AECB

Laboratory Tests

Gram Stain/Culture

 Sputum Gram stain & culture should be limited to patients w/ end-stage COPD,
frequent exacerbations or bronchiectasis in whom the presence of more virulent &/or
resistant bacteria is more likely
o Gram stain/culture has a limited role in the investigation of AECB since 30-
50% of chronic bronchitis sufferers are colonized w/ non-encapsulated
Haemophilus influenzae, Streptococcus pneumoniae & Moraxella catarrhalis

Pulmonary Function

 Pre-morbid forced expiratory volume in 1 sec (FEV1) values are a predictor of

adverse outcomes during an AECB but it is not necessary to perform FEV1 during the
actual exacerbation
o There is no clear correlation between transient falls in lung function & the
severity of exacerbation
o Objective measurements of pulmonary function should be done after the
recovery of patients w/ AECB

Arterial Blood Gas

 Measurement of O2 saturation (+/- blood gases) is recommended in moderate to

severe cases to guide therapy

Imaging

Chest X-Ray

 Chest x-ray is not helpful in making the diagnosis of AECB

o May consider if needed to exclude other diseases that may complicate the
condition eg pneumonia or chronic heart failure (CHF)

Evaluation

Severe Exacerbation

 Severe exacerbation is considered when all 3 major criteria are present:

o Increase in sputum volume, increase in sputum purulence & increased dyspnea

 Patients w/ severe exacerbations are more likely to benefit from antibiotic treatment
Moderate Exacerbation

 Moderate exacerbation is considered when 2 of the 3 major criteria are present

 These patients may benefit from antibiotic treatment

Mild Exacerbation

 Mild exacerbation is considered when 1 of the major criteria is present along w/ at

least 1 minor criteria
 Studies have shown that antibiotics are generally no more effective than placebo in
these patients

Principles of Therapy

 Rapid resolution of symptoms

 Prevent transient loss of pulmonary function
 Reduce the bacterial burden in the lower respiratory tract
 Prevent relapse or lengthen the time between exacerbations
 Re-evaluation of the disease to reduce the risk of future exacerbations

Pharmacotherapy

Bronchodilators

 Bronchodilators should be used for the treatment of dyspnea accompanying an

exacerbation

Short-Acting Anticholinergics (Inhaled)

 Eg Ipratropium bromide
 Effects: An effective bronchodilator with a slower onset of action and a slightly
longer duration of action compared to short-acting beta2-agonists, but no appreciable
difference between the two in terms of effects on pulmonary function
o Decreased cough frequency & sputum volume have been noted in patients
using Ipratropium
o Side effects may be fewer compared to Salbutamol

 Available in metered-dose inhalers (MDIs) and nebulizer solution

o There is no significant difference in pulmonary function outcomes between
delivery system, but in most situations, MDIs with an appropriate spacer
would be preferred

Short-Acting Beta2-Agonists (Inhaled)

 Short-acting inhaled beta2-agonists are usually the preferred bronchodilators

o Addition of anticholinergics is recommended should there be no prompt
response with inhaled beta2-agonists
  Produce effective bronchodilatation with a faster onset of action than anticholinergics,
but no appreciable difference between the two in terms of effects on pulmonary
function
 Available in MDI and nebulizer solution
 The role of long-acting beta2-agonists has not been studied in AECB therefore are not
recommended for treatment of the condition at the present time

Methylxanthines

 The use of methylxanthines in AECB does not appear to be indicated

o The addition of Aminophylline to inhaled bronchodilators does not appear to
improve FEV1

 Patients already on methylxanthines should continue the medications but monitor for
drug interactions with antibiotics

Corticosteroid Hormones

 The use of oral or parenteral steroids is supported for most patients with moderate to
severe AECB
 Action: Reduce airway edema & mucus hypersecretion
 Effects: Rapid improvement in pre- & post-bronchodilator FEV1, rapid recovery of
partial pressure of O2, decreased treatment failures, shorter hospitalization rates, speed
up recovery in AECB & may reduce the frequency of exacerbations & likelihood of
relapse

Inhaled Corticosteroid Hormones

 Recommended when airflow obstruction is severe or very severe (eg FEV1 <50%) &
when there is a history of frequent exacerbations
 May be given in stable patients w/ chronic bronchitis together w/ a long-acting beta2-
agonist to control chronic cough

Systemic Corticosteroid Hormones

 Beneficial in cases of significant pulmonary compromise, particularly if the patient

requires hospitalization
 Treatment is recommended for 5-14 days
 The exact dose & duration of therapy should be individualized
o Eg the use of high-dose & prolonged steroids must be carefully weighed in the
elderly patients
o Prednisone PO is usually used initially at a dosage of 0.5-1.0 mg/kg/day &
then tapered at a rate & duration based on response

 Methylprednisolone 40-125 mg IV 8-12 hourly or Hydrocortisone 100 mg IV 6-8

hourly may be used initially in severely ill patients or in patients who are unable to
take oral medications
 In studies, the major side effect in the steroid-treated group was hyperglycemia

Empiric Antibiotic Therapy

Based on the current available evidence, antibiotic therapy should be given in patients with
exacerbations of COPD if:

 With presence of the 3 cardinal symptoms (increased dyspnea, increased sputum

purulence & increased sputum volume)
 Two of the cardinal symptoms are present with increased sputum purulence as one of
the 2 symptoms
 The exacerbation is severe requiring mechanical ventilation (invasive or non-
invasive)

Therapy should be based on local resistance patterns along with patient risk stratification
to prevent therapeutic failure

 Some studies have shown that severity of bronchitis is an important determinant of

the type of pathogen
o S pneumoniae predominates in patients with mild exacerbation
o H influenzae & M catarrhalis are the frequent pathogens as FEV1 declines &
patients have more frequent exacerbations &/or comorbid diseases
o P aeruginosa may be present in those with severe airway restriction

 Antibiotics used should have significant in vitro & in vivo activity against the
pathogens most commonly associated with AECB, including H influenzae, S
pneumoniae & M catarrhalis
 In patients with more severe airway obstruction, coverage may need to be extended to
include other potential pathogens eg Gram-negative bacilli
 Aminopenicillins, Co-trimoxazole & Doxycycline are considered 1st-line antibiotics
for AECB
 Amoxicillin/clavulanic acid, macrolides, 2nd- or 3rd-generation cephalosporins &
quinolones are good alternatives in areas with increasing antibiotic resistance to older
agents

Aminopenicillins

 Recommendation for treatment of simple AECB with aminopenicillins is justified

since there are no clinical or pharmacoeconomic studies showing the advantage of
more potent agents
o Studies showing the effectiveness of these agents are >10 years old & were
performed prior to the current concerns regarding antibiotic resistance

 No activity against atypical & beta-lactamase-producing pathogens, limited activity

against Enterobacteriaceae
 High dose is effective against Penicillin-resistant S pneumoniae

Aminopenicillin/Beta-lactamase Inhibitors

 Covers major bacterial pathogens including beta-lactamase-producing pathogens,

moderate activity against Enterobacteriaceae, but no activity against atypical
pathogens
 High dose of Aminopenicillin component is effective against Penicillin-resistant S
pneumoniae
  Short-term effectiveness of Amoxicillin/clavulanic acid is equivalent to that of
macrolides & quinolones

Cephalosporins (2nd & 3rd Generation)

 If resistant S pneumonia & H influenzae is a concern, selected 2nd & 3rd generation
cephalosporins may be preferred over older agents
 Offer enhanced stability against beta-lactamases of H influenzae, H parainfluenzae &
M catarrhalis & improved efficacy against Penicillin-susceptible S pneumoniae &
Methicillin-susceptible S aureus

Co-trimoxazole [Sulfamethoxazole (SMZ) & Trimethoprim (TM)]

 Recommendation for treatment of simple AECB with Co-trimoxazole is justified

since there are no clinical or pharmacoeconomic studies showing the advantage of
more potent agents
o Studies showing the effectiveness of this agent are >10 years old & were
performed prior to the current concerns regarding antibiotic resistance

 Covers major bacterial pathogens, no activity against atypical pathogens & resistance
in S pneumoniae is common; resistance limits its usefulness
 May be an acceptable alternative for patients who are allergic to Penicillin

Doxycycline

 Recommendation for treatment of simple AECB with Doxycycline is justified since

there are no clinical or pharmacoeconomic studies showing the advantage of more
potent agents
o Studies showing the effectiveness of this agent are >10 years old & were
performed prior to the current concerns regarding antibiotic resistance

 Covers major bacterial & atypical pathogens, but S pneumoniae resistance is common
 Alternative to quinolones and macrolides when atypical coverage is required
 Acceptable as an alternative for patients who are allergic to Penicillin, cephalosporins
and newer macrolides

Advanced Macrolides & Ketolide

 If resistant S pneumoniae & H influenzae are a concern, advanced macrolides may be

preferred over older agents
 Active against atypical pathogens, not active against Enterobacteriaceae, &
macrolide-resistant S pneumoniae is common but this does not appear to reduce
clinical effectiveness
o Ketolide is effective against macrolide-resistant strains of S pneumoniae

 Reasonable option in beta-lactam allergic patients

Quinolones

 Has good tracheobronchial penetration

  Cover all major bacterial and atypical pathogens as well as Enterobacteriaceae &
some agents cover P aeruginosa
 Quinolones with enhanced activity to drug-resistant S pneumoniae are preferred
o Eg Levofloxacin, Moxifloxacin

 Ciprofloxacin
o Considered 1st-line agents in ambulatory AECB patients only if P aeruginosa
coverage is required
o Least active against S pneumoniae & should not be used routinely in the
management of AECB; most active against P aeruginosa

Other Pharmacotherapy Agents

 Expectorants/cough suppressants have not been shown to improve lung function or

hasten the clinical recovery but may produce a subjective improvement
 Chronic use of mucolytics helps reduce the frequency of exacerbations & days of
illness but does not improve ventilatory function
 Chest physiotherapy has not been shown to improve lung function or hasten clinical
recovery in AECB
 There is still no evidence supporting the use of leukotriene receptor antagonists in
AECB

Prevention

Influenza Vaccine

 The use of an annual influenza vaccine for all patients with chronic bronchitis is
strongly recommended
o Patients with chronic lung disease have a higher risk of complications from
influenza infection

 See Influenza Disease Management Chart for complete details

Pneumococcal Vaccine

 It is recommended that pneumococcal vaccine be administered at least once to

patients with chronic bronchitis
o Consider repeating vaccine every 5-10 years in high-risk patients

 Pneumococcal vaccine is safe & may reduce invasive pneumococcal infection in

patients with COPD

Patient Education

 Educate patient about the nature of the chronic bronchitis (the progressive nature & its
potential impact on future lifestyle & function)
 Review w/ the patient the signs of onset of infection (eg increased purulence,
viscosity or volume of secretions) that should be treated early
 Discuss measures that may limit the spread of viral infections (eg hand washing)
 Encourage patients to exercise regularly
 o Although not accompanied by measurable improvement in lung function, it
will increase exercise tolerance & improve the patient’s sense of well-being

Lifestyle Modification

Smoking Cessation

 A discussion of smoking behavior and the setting of a specific cessation date should
be part of every physician-patient encounter
 Patients presenting with AECB should be encouraged to stop smoking since it is the
most effective way to reduce the risk of future morbidity from chronic bronchitis
 It can lead to dramatic symptomatic benefits for patients with chronic bronchitis eg
stopping cough in 94-100%; when coughing stops, it can occur in as quickly as 4
weeks in 54% of patients

Reduction/Elimination of Irritants

 Reduction or elimination of any source of irritants that may worsen lower airway
inflammation
o Includes environmental pollutants (eg dust, pollutants & second-hand smoke)
& occupational irritants